Editing Apgar score (section)

=== Implementation ===
[[File:HumanNewborn.JPG|thumb|Newborn crying right after birth]]
In cases where a newborn needs resuscitation, it should be initiated before the Apgar score is assigned at the one-minute mark. Therefore, the Apgar score is not used to determine if initial resuscitation is needed, rather it is used to determine if resuscitation efforts should be continued. Variation between the one-minute and five-minute Apgar scores can be used to assess an infant's response to resuscitation. If the score is below seven at the five-minute mark, the Neonatal Resuscitation Program guidelines specify that the infant's Apgar score should be reassessed at five-minute intervals for up to 20 minutes.<ref name=":0" />

Exceedingly few infants who have an Apgar score of 0 at 10 minutes of age survive with intact neurological function. As a result, the 2011 Neonatal Resuscitation Program suggests that if no pulse is appreciable at 10 minutes of life, "discontinuation of resuscitative efforts may be appropriate."<ref name="Newborn 819–822"/> However, in a recent retrospective study including 17 infants with an Apgar score of 0 at 10 minutes who received [[therapeutic hypothermia]], 4 of the 8 surviving babies had no neurological abnormalities, and only one infant had severe abnormalities, as assessed through [[Magnetic resonance imaging of the brain|brain MRI]].<ref>{{Cite journal|last1=Ayrapetyan|first1=Marina|last2=Talekar|first2=Kiran|last3=Schwabenbauer|first3=Kathleen|last4=Carola|first4=David|last5=Solarin|first5=Kolawole|last6=McElwee|first6=Dorothy|last7=Adeniyi-Jones|first7=Susan|last8=Greenspan|first8=Jay|last9=Aghai|first9=Zubair H.|date=April 2019|title=Apgar Scores at 10 Minutes and Outcomes in Term and Late Preterm Neonates with Hypoxic-Ischemic Encephalopathy in the Cooling Era|journal=American Journal of Perinatology|volume=36|issue=5|pages=545–554|doi=10.1055/s-0038-1670637|issn=0735-1631|pmc=8039809|pmid=30208498}}</ref> 

During neonatal resuscitation, Apgar scores may not accurately represent the condition of the neonate as resuscitation measures (i.e. positive pressure ventilation and chest compressions) may artificially elevate scores. As a result, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists encourage the use of an expanded Apgar score report, which records resuscitation efforts utilized at each time point.<ref name="Newborn 819–822"/>

A systematic review that analyzed the relationship between umbilical cord pH and neonatal outcomes found that low cord pH is strongly correlated with mortality, morbidity and cerebral palsy in childhood.<ref>{{cite journal | vauthors = Malin GL, Morris RK, Khan KS | title = Strength of association between umbilical cord pH and perinatal and long term outcomes: systematic review and meta-analysis | journal = BMJ | volume = 340 | issue = may13 1 | pages = c1471 | date = May 2010 | pmid = 20466789 | pmc = 2869402 | doi = 10.1136/bmj.c1471 }}</ref> To reduce the risk of negative outcomes, it is recommended to obtain a sample of the umbilical artery blood gas when a newborn has an Apgar score of five or less at the five-minute mark.<ref name=":0" />

Recognizing the importance of skin to skin contact (SSC), the [[World Health Organization]] (WHO), as part of the [[Baby Friendly Hospital Initiative]], recommends that the Apgar score should be done while SSC is underway whenever possible.<ref name=":6">{{Cite journal|last1=Feldman-Winter|first1=Lori|last2=Goldsmith|first2=Jay P.|last3=Newborn|first3=Committee on Fetus And|last4=Syndrome|first4=Task Force on Sudden Infant Death|date=2016-09-01|title=Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns|journal=Pediatrics|volume=138|issue=3|pages=e20161889|language=en|doi=10.1542/peds.2016-1889|issn=0031-4005|pmid=27550975|s2cid=19866683|doi-access=free}}</ref> This recommendation was adopted by the [[American Academy of Pediatrics]] in 2009.<ref name=":6" />